NR 443 Chapter 16: Cognitive Disorders:
Delirium, Dementia, and Amnestic Disorders
Fortinash: Psychiatric Mental Health Nursing, 5th Edition
Chapter 16: Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders
Test Bank
MULTIPLE CHOICE
1. A patient diagnosed with moderate dementia consistently appears to be distorting the truth
resulting in his wife asking, “What should I do when he lies to me about unimportant things?”
Upon what rationale should the nurse’s response be based?
a. Changing the topic provides diversion.
b. Delusions should be confronted to clarify thinking.
c. Ignoring memory deficit avoids catastrophic reactions.
d. This isn’t lying but rather a way to fill in the memory gaps.
ANS: D
Confabulation is not lying but rather a method for filling in the memory gaps. Ignoring, using
confrontation, and changing the topic would not be as useful as gently reorienting.
DIF: Cognitive Level: Application REF: Page 374
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental
State Examination (MMSE) as one component. When the nurse arrives, the patient is seated at
the table with her husband, the TV is on, and several grandchildren are visiting. The patient is
quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the
nurse to take would be which of the following?
a. Ask the husband to make an appointment to bring his wife to the clinic for testing.
Explain to the husband that accurate data will be sought, and ask him to stay with the
b. grandchildren in another room.
c. Do not perform the test during the assessment (because it will not be valid) and rely on
, observations and reports from the family.
Explain the importance of the testing process and make an appointment for another day
d. when the environment can be better controlled.
ANS: D
Testing the patient in her home under quieter, less distracting circumstances is the best solution.
Asking the husband to leave is likely to increase the patient’s anxiety and alter test results. Use
of the MMSE is an integral component of the assessment and must not be deleted. Testing in the
more familiar, comfortable surroundings of the home will yield more reliable results.
DIF: Cognitive Level: Application REF: Page 378
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
3. A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing
intervention is supported by this diagnosis?
a. Encouraging fluids to minimize constipation
b. Frequently assessing both visual and auditory hallucinations
c. Scheduling frequent changing of position to prevent skin breakdown
d. Dimming the lights to help control eye discomfort resulting from cataracts
ANS: C
Because of inactivity, hypoactive delirium patients are more likely to develop further
complications, including decubiti that could be minimized by frequent repositioning. The
remaining options identify interventions that are not generally a result of this diagnosis.
DIF: Cognitive Level: Application REF: Page 377 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
4. Which of the following should the nurse use as a basis for explaining the etiology of
Alzheimer’s disease to the family of a patient with this disease?
It is a secondary dementia indicated by loss of recent memory and disorientation to time
a. and place.
It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence
b. of a beta-amyloid protein in the neurons resulting in senile plaques.
Delirium, Dementia, and Amnestic Disorders
Fortinash: Psychiatric Mental Health Nursing, 5th Edition
Chapter 16: Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders
Test Bank
MULTIPLE CHOICE
1. A patient diagnosed with moderate dementia consistently appears to be distorting the truth
resulting in his wife asking, “What should I do when he lies to me about unimportant things?”
Upon what rationale should the nurse’s response be based?
a. Changing the topic provides diversion.
b. Delusions should be confronted to clarify thinking.
c. Ignoring memory deficit avoids catastrophic reactions.
d. This isn’t lying but rather a way to fill in the memory gaps.
ANS: D
Confabulation is not lying but rather a method for filling in the memory gaps. Ignoring, using
confrontation, and changing the topic would not be as useful as gently reorienting.
DIF: Cognitive Level: Application REF: Page 374
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental
State Examination (MMSE) as one component. When the nurse arrives, the patient is seated at
the table with her husband, the TV is on, and several grandchildren are visiting. The patient is
quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the
nurse to take would be which of the following?
a. Ask the husband to make an appointment to bring his wife to the clinic for testing.
Explain to the husband that accurate data will be sought, and ask him to stay with the
b. grandchildren in another room.
c. Do not perform the test during the assessment (because it will not be valid) and rely on
, observations and reports from the family.
Explain the importance of the testing process and make an appointment for another day
d. when the environment can be better controlled.
ANS: D
Testing the patient in her home under quieter, less distracting circumstances is the best solution.
Asking the husband to leave is likely to increase the patient’s anxiety and alter test results. Use
of the MMSE is an integral component of the assessment and must not be deleted. Testing in the
more familiar, comfortable surroundings of the home will yield more reliable results.
DIF: Cognitive Level: Application REF: Page 378
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
3. A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing
intervention is supported by this diagnosis?
a. Encouraging fluids to minimize constipation
b. Frequently assessing both visual and auditory hallucinations
c. Scheduling frequent changing of position to prevent skin breakdown
d. Dimming the lights to help control eye discomfort resulting from cataracts
ANS: C
Because of inactivity, hypoactive delirium patients are more likely to develop further
complications, including decubiti that could be minimized by frequent repositioning. The
remaining options identify interventions that are not generally a result of this diagnosis.
DIF: Cognitive Level: Application REF: Page 377 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
4. Which of the following should the nurse use as a basis for explaining the etiology of
Alzheimer’s disease to the family of a patient with this disease?
It is a secondary dementia indicated by loss of recent memory and disorientation to time
a. and place.
It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence
b. of a beta-amyloid protein in the neurons resulting in senile plaques.
